Rolling Back Malaria: a Multi-Sectoral Challenge
by Obreniokibo I. Amiesimaka
October 2018 marked the 20th anniversary of the now-rebranded RBM Partnership to End Malaria. Originally called Roll Back Malaria, RBM was founded by the World Health Organisation (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank.
With its foundation set on collaboration, it was charged with building a partnership of stakeholders in order to spearhead the global effort in combatting malaria.
The RBM Partnership has brought together over 500 partners from diverse fields; ranging from the academia and malaria-endemic countries to the donor, public and also private sectors, amongst many others. This collaborative approach – and work in line with Millennium Development Goal (MDG) 6: “combat HIV/AIDS, malaria and other diseases” – yielded fruits. In the 17 years from its inception to 2015, the WHO records that more than 6 million lives were saved and there was a significant reduction of about 18% in the global burden of malaria.
Its technique is succinctly described in the Stanford Social Innovation Review thus:
“RBM …has never treated a patient; nor has it delivered a single bed net or can of insecticide. Rather, RBM has worked across the field of malaria eradication by helping to build public awareness, aggregate and share technical information with a system of global stakeholders, and mobilize funding“.
In 2016, RBM underwent a governance overhaul, which led to its rebranding, in order to reposition it to better meet the malaria challenge. With the launch of the Sustainable Development Goals (SDGs) the year previous, RBM and other global health initiatives are adopting more holistic strategies which recognize the linkages between other social factors and health.
The WHO issued its Global Technical Strategy (GTS) for Malaria 2016 – 2030, which has a similar timeline to the SDGs. Compared to 2015 figures, by 2030, it aims to reduce malaria mortality and incidence rates both by 90%. The elimination of malaria from a minimum of 35 countries and prevention of re-establishment in already malaria-free countries are further targets.
In congruence with the GTS, RBM also published its Action and Investment to defeat Malaria 2016-2030 (AIM) policy. The fulcrum of the AIM document is four-fold: ‘Combine forces to defeat malaria’; ‘Demonstrate continued progress’; ‘Expand partnerships’ and ‘Accelerate efforts’. The AIM document also highlights the importance of malaria eradication to the achievement of the SDGs.
Progress made in the execution of the GTS and AIM documents has been monitored and is explored below.
There is no gainsaying that RBM has achieved remarkable success in the fight against malaria. As a result of its work, countries with less than 10,000 malaria cases have risen to an unprecedented 44. Further, whereas 10 countries are poised to completely eradicate malaria by 2020, eight (8) have already done so since 2010; with two joining the ranks after 2016. They include Armenia, Kyrgyzstan, Maldives, Morocco, Paraguay, Sri Lanka, Turkmenistan and United Arab Emirates.
More so, the proportion of the African population with access to long-lasting insecticide treated nets, has increased from a 2001 figure of just 2% to more than 50%. Notwithstanding the progress made, malaria still remains a top-10 killer in low-income countries and a major burden on global health.
The WHO World Malaria Report 2017 estimates that there was an unfortunate rise in the number of people with malaria of 5 million between 2015 and 2016. Similarly, the number of deaths stagnated at about 445,000 between those two years. Although there was still an overall decrease in malaria cases from 273 million in 2010 to 216 million in 2016, it is worrying to see that the progress made thus far could be reversed.
Africa bears the majority of the malaria burden with 91% of deaths and 90% of cases globally. Even more troubling is the fact that 80% of cases are found in just 15 African countries. Malaria is also a sizeable problem in South-East Asia and South America.
Additionally, inadequate funding continues to hamper the achievement of the GTS goals. An estimated USD 2.7 billion was spent in 2016 on malaria but this is less than half the amount needed annually – USD 6.5 billion by 2020 – as stated in the GTS.
According to the WHO, groups at high risk of malaria infection include: patients with HIV/AIDS, infants, children less than 5 years old and pregnant women, coupled with non-immune migrants, mobile populations and travellers.
Given the impact of malaria on these vulnerable groups, many of whom constitute the future of society, the need for progress in the fight against malaria cannot be overemphasized.
Some social factors which play a role in the spread of malaria, and are thus of substantial importance, are explored below.
Multi-sectoral factors at play
There is a strong correlation between poverty and malaria. The world regions with the highest burden are also the poorest. People living in poverty often reside in conditions with fertile breeding grounds for mosquitos – the vector for the malaria parasite. When they fall ill with malaria they are unable to work and earn a living; resulting in a lack of money.
As the poor often have little education and earning power, they have limited access to healthcare. The inability to pay for treatment of malaria leads to worse health outcomes for them and prolonged durations out of work. Thus develops the malaria-poverty cycle.
The WHO has noted the impact gender roles and living patterns have on susceptibility to malaria. In different community settings, men or women have higher risks of contracting malaria. Working in the forests, mines or fields often put men at a high risk of infection. Also, pregnant women are particularly susceptible to malaria, which can seriously affect the health of both mother and unborn child.
Furthermore, women are often the primary caregiver for children; hence, when the children fall ill, the women are unable to work as they must care for the sick child. In large families, this can consume a sizeable amount of the women’s time. Gender-based power imbalances also disadvantage women as, in many cases, they must seek the permission of men before accessing healthcare when they fall ill.
Household duties specific to women such as early rising to fetch water – sometimes involving treks over long distances – and outdoor cooking increase women’s risk of infection.
Given the aforementioned, collaboration with partners dealing with gender issues could help further the anti-malaria effort.
The impact of education on access to treatment and childhood mortality has been well established. Better education levels of mothers and caregivers have been shown to positively affect the chances of children getting needed malaria treatment and thus surviving childhood.
The anti-malaria effort also positively affects access to education. When children do not fall ill with malaria, they and their elder siblings – who might otherwise have to care for them – are able to attend school.
Consequently, combatting malaria is important to education and thus social development.
Food and Agriculture
Malaria has been linked to agriculture and food production; certain agricultural methods e.g. irrigation schemes, can contribute to its spread. The availability of stagnant water – breeding grounds for mosquitoes – and exposure to the vector in the course of farming and animal husbandry are factors to consider.
As agriculture is a major contributor to many countries’ economic output, malaria infection impacts negatively on the labour force and thus agricultural production levels. Consequently, as most malaria-endemic countries are in the low and middle income bracket, with large agrarian populations, the anti-malaria effort is of great importance to them.
Housing and urban development are a veritable tool in the fight against malaria. Appropriate building designs and town planning can limit hiding and breeding places for mosquitoes. However, if improperly done, the opposite can result. Some designs can lead to the creation of favourable circumstances for the vector and thus further the spread of malaria.
Urban slums, with their concomitant poor planning and sanitation, are a major challenge to malaria eradication. Around 823 million people live in slums around the globe, many of whom are at risk of malaria infection. They will benefit greatly from better housing conditions through reduced risk of infection.
The association between malaria and weather/climatic conditions has been evidenced by many scientific studies. The World Meteorological Organisation (WMO) and the WHO highlight the fact that climate change increases number of people at the risk of malaria and other vector-borne diseases.
Higher temperatures, humidity and rainfall provide the required conditions for mosquitoes to breed and spread malaria; additionally, monsoon rains have long been seen to lead to an increase in malaria. Countries such as Botswana have developed a climate-based early warning system to predict and hence prevent malaria epidemics. This allows for an additional four months in the warning period; useful time for the country to take action and help protect vulnerable populations from malaria.
Noteworthy is news that West Nile Fever – a disease spread by another type of mosquitoes – has been on the rise in Europe. This occurrence has been attributed to increased rainfall and temperatures.
Understanding this link, the RBM Strategic Plan takes cognizance of the need for collaboration between anti-malaria advocates and players in not just the health sector but also in environmental development.
Given the aforementioned, which highlight but a few of the social factors that are inextricably linked with the spread of malaria, RBM made sure to include them in its strategy for 2018-2020. RBM is to transform into a ‘multi-sectoral partnership’ and recognizes the fact that social factors such as poverty, gender roles, education and such like, play a role in the spread of malaria.
Specifically, it states that
“This strategy therefore identifies key sectors such as education, the extractive industries, housing, agriculture, environment, tourism and transport sectors as potential trailblazers in malaria multi-sectoral engagement at all levels“.
Achieving the goals outlined in the WHO Global Technical Strategy will require sustained intervention effort and collaboration across many fields and stakeholders. It is refreshing that the RBM has been repositioned to achieve this but the shortfalls in progress show that there remains a long way to go.